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Applications Will Be Pi aseu When Submitted Properly Completed. Be , Ign The Application. <br /> OFFICE USE ONLY <br /> For Calendar Year Area <br /> Multiple Years(Permanent Housing Camps) APPLICATION <br /> Condition 1 Permi Date Approved <br /> I.D. No.. (For Non-Transferable, Revocable, Suspendable) permit _ <br /> ENVIRONMENTAL HEALTH PERMIT <br /> Date Mailed _ <br /> TO OPERATE <br /> EMPLOYEE HOUSING OR LABOR CAMP New_ Existing ``// <br /> FEE IS DUE WITH APPLICATION Change 00S s.l <br /> Location <br /> Operator <br /> Address _ Telephone No. <br /> Legal Owner New Owner Yes _No <br /> Address _ __ Telephone No. <br /> No. Employees Housed Occupancy Dates From To Crop <br /> From To Crop <br /> Total Number Days Used This Calendar Year <br /> Total Days Ocupied by 25 or more employees e <br /> (Camps Occupied by 25 or more employees for 60 or more Bays require <br /> a public water system permit-) <br /> Inactive— IMPORTANT. If this camp is not to be used this year but is intended for use in the future, this application is to be <br /> returned marked "Inactive" too protect your land use status. <br /> FEE SCHEDULE <br /> Permanent Camps Annual Permit$35.00 + No. Employees ® $12.00 each = $ <br /> Orchard Camps$95.00 Transfer of Ownership $20.00 <br /> Amend Permit $20.00 + — __ Additional Employees ® $12.00 each = $ <br /> Late Application Penalty Fee$70.00 + Employees ® $24.00 each = $ <br /> Applicant agrees to all necessary inspections incident to issuance of permit to operate. <br /> Applicant agrees that this project shall be operated and maintained in accordance with the Applicable provisions of the Employee <br /> Housing Act, Chapter 1, Part 1, Division 13 of the Health and Safety Code and Chapter 1, Subchapter 3, Title 25, CCR. <br /> Please remit in the enclosed self-addressed envelope together with applicable fee. DO NOT SEND CASH. <br /> Date Signed X Title <br /> • Contact Environmental Realth for Laforsation and application for <br /> a public vater system permit. <br /> FOR DEPARTMENT USE ONLY <br /> Fee*Is Due: L1 ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑Jams I a Received By Janu 31 ❑Jul 1 8 Recalvad By July 31 <br /> BILLING REMITTANCE E REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE <br /> Less <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> OTHER <br /> Received by Data Receipt No. Per.4 No. lesuarwe Deal Mailed Delivered <br /> APPLICANT—RETURN ALL COPIEB TO: ENVIRONMENTAL HEALTH PERMIT/SERwCU p O Box 2009 STOCKTON.CA 95201 <br /> OFFICE ADDRESS EHJY150(I I/aS) <br /> 445 N.SAN JOAOUIN ST..STOCKTON.CA <br /> (NO MAIL IS RECEIVED AT THIS ADDRESS) Pho-e (209) 468-3420 <br />